Awais, I was disappointed that you did not respond to my comment last week. After a week's thought, I think my point still holds. Psychiatrists hardly ever see their patients for prolonged periods, so they never have direct experience with the reality that the same med will work very well for some and be very detrimental to others. Psychiatrists have less of a chance to see the pros and cons of a treatment.
Sorry about that. Not being able to follow patients over extended periods does lead to a distorted assessment of how meds affect people over time. For example, many inpatient psychiatrists prefer sedating, appetite-boosting meds because they work great in short-term while I actively avoid many of those meds in the outpatient setting. That said, I believe following patients over long periods is the expected norm in outpatient settings (similar to primary care) but practically, treatment may get interrupted because people switch jobs, patients relocate or life intervenes in other ways.
I realize that I am thinking from an American perspective where short term treatment is the only kind funded by insurance companies. As far as I understand, you primarily work with patients that you met via hospitalization. In the United States, it is a lot harder to access long term psychological care (paid for by insurance) if you're not suffering enough to need hospitalization.
Psychiatrist get more than sufficient time develope the pattern recognition required to know if a drug will work for a given patient. The problem is one of pharmaceutical company marketing. Pharmaceutical companies have slyly trashed attempts to refine treatments and even succeed in convincing doctors that psychiatric diseases cannot be properly separated.
The message that different drugs work differently for different people is true up to a point but consider how useful such a mantra is to drug companies. Now when a dozen drugs fail to work, they can simply blame the individual for not being the "right" person. Broadly speaking drugs have similar effects in most people. Think of alcohol, some people may be lightweights but it's not as if there are enormous gaps in experience.
The real issue is that good drugs, drugs that worked for a lot of people, have been pushed aside for new drugs that suck. Yes, they "suck". I know that's not very scientific but it's really the only sensible way to describe most of them.
The other issue is that psychopathology also sucks. All this talk of comorbidities, and overlap, it's nonsense at face value, yet most doctors believe they're somehow being more parsimonious by considering these problems. Consider again how much this state of affairs benefits manufacturers. Now they can make one drug and roll it right across all the golden field of overlapping comorbidities. The side effects might even give you a few new ones.
I have been on four different SSRIs and each of them had a different impact on me. Many of the psychiatric patients who have commented on this site have similar stories to tell. I'm sure that drug companies impact prescribing decisions, but I have no personal experience of that affecting my treatment. I have been on this same SSRI for more than 10 years now and it effectively prevents panic attacks.
Sorry, you’re right, my first comment lacks nuance and was too one-sided.
Yes, SSRIs have a quite powerful anxiolytic effect. It was Donald Klein who along with Max Fink discovered in 1962 and further reported on in 1964 that the first antidepressant imipramine could effectively terminate panic attacks.
His description of the specific type of attack is as follows:
"Typically, these patients noted the sudden onset of subjectively
inexplicable panic attacks, accompanied by hot and cold flashes, rapid
breathing, palpitations, weakness, unsteadiness and a feeling of impending
death."
While SSRIs can work well as anxiolytics, there has long been debate about whether they have as marked an effect on true panic attacks. So, perhaps you can help answer a burning scientific question: the panic attacks you experienced, were they “bolt-from-the-blue” episodes with sudden hyperventilation to the point of near blacking out followed by fear, or were they more like an overwhelming surge of anxiety that came from nowhere and involved only slight hyperventilation?
Just to clarify a litte more what I was getting at before:
The point I was trying to make is that the “your mileage may vary” mantra is a thought-terminating cliché. It’s like, when Tony Soprano says “yeah, but what are you going to do about it?”. It’s a throwaway line that immediately stops people thinking any harder about the problem.
It also teaches consumers that their experiences are part of some cosmic mystery, to be accepted, not investigated. A bit like the saying some religious folk once had, “the Lord works in mysterious ways”, so too, according to some, do all psychiatric drugs. There might be a kernel of wisdom in accepting that these drugs can be a little mysterious, but it is hardly satisfactory to leave the matter at that.
I believe that when you listen to people's lived experiences, you start to see patterns. You start to realise that many people have had the same experience. You start to realise that some of these experiences may be explainable. You start to realise that people deserve answers.
Once again, an approach to psychiatry that is hyperindividualistic, and rooted in the computer model. But humans are not fundamentally individualistic, we begin life as a dyad (mother-infant) and the quality of that dyad is literally of life and death importance. We continue through life as nodes in a web of relationships, with our moods, behaviors, and thoughts profoundly shaped by this web. WE value connection and relational warmth in the web more than we value alleviation of our suffering. Clients are willing "to receive an intervention that had a lower recovery rate by 38.14% to ensure that they received a therapist with whom they
could develop a positive working relationship. " JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(12), 1217--1231 (2010). Until theories of mental health/disorder start from perspective of the relationships between people, they will be woefully incomplete, giving into the reductionism of science, rather than the social web that weaves us together from infancy to death.
Relational aspects are of course quite important and not denied by neuroscience. It is difficult to study the brain without taking into account social and environmental interactions, especially during development, and systems neuroscience is interested in that. Neuroscience is not a substitute for psychological and social disciplines; some things are better studied by other disciplines and that’s not changing. You may not believe that neuroscience is of any importance to the study of mental health problems and to the development of new treatments. I don’t agree with that but I know some people hold that view. For those of us who do believe in the importance and relevance of neuroscience (along with other disciplines), these developments are positive and promising. Neuroscience is still in infancy and there is a long way to go.
Ruth Feldman's brilliant work shows that the infant's brain is wired by the interactions with the mother, and its socio-emotional development is highly dependent on this wiring. This carries on for years, as "Exposure to childhood sexual abuse was specifically associated with pronounced
cortical thinning in the genital representation
field of the primary somatosensory cortex. In
contrast, emotional abuse was associated with
cortical thinning in regions relevant to self-awareness
and self-evaluation (Am J Psychiatry 2013; 170:616–623) It is only by understanding the web of relationships the person was raised in, and interacts in, that we can make sense of the results of current neuroscience findings.
Awais, I was disappointed that you did not respond to my comment last week. After a week's thought, I think my point still holds. Psychiatrists hardly ever see their patients for prolonged periods, so they never have direct experience with the reality that the same med will work very well for some and be very detrimental to others. Psychiatrists have less of a chance to see the pros and cons of a treatment.
https://www.psychiatrymargins.com/p/why-has-critical-psychiatry-run-out/comment/155705496
Sorry about that. Not being able to follow patients over extended periods does lead to a distorted assessment of how meds affect people over time. For example, many inpatient psychiatrists prefer sedating, appetite-boosting meds because they work great in short-term while I actively avoid many of those meds in the outpatient setting. That said, I believe following patients over long periods is the expected norm in outpatient settings (similar to primary care) but practically, treatment may get interrupted because people switch jobs, patients relocate or life intervenes in other ways.
I realize that I am thinking from an American perspective where short term treatment is the only kind funded by insurance companies. As far as I understand, you primarily work with patients that you met via hospitalization. In the United States, it is a lot harder to access long term psychological care (paid for by insurance) if you're not suffering enough to need hospitalization.
Psychiatrist get more than sufficient time develope the pattern recognition required to know if a drug will work for a given patient. The problem is one of pharmaceutical company marketing. Pharmaceutical companies have slyly trashed attempts to refine treatments and even succeed in convincing doctors that psychiatric diseases cannot be properly separated.
The message that different drugs work differently for different people is true up to a point but consider how useful such a mantra is to drug companies. Now when a dozen drugs fail to work, they can simply blame the individual for not being the "right" person. Broadly speaking drugs have similar effects in most people. Think of alcohol, some people may be lightweights but it's not as if there are enormous gaps in experience.
The real issue is that good drugs, drugs that worked for a lot of people, have been pushed aside for new drugs that suck. Yes, they "suck". I know that's not very scientific but it's really the only sensible way to describe most of them.
The other issue is that psychopathology also sucks. All this talk of comorbidities, and overlap, it's nonsense at face value, yet most doctors believe they're somehow being more parsimonious by considering these problems. Consider again how much this state of affairs benefits manufacturers. Now they can make one drug and roll it right across all the golden field of overlapping comorbidities. The side effects might even give you a few new ones.
I have been on four different SSRIs and each of them had a different impact on me. Many of the psychiatric patients who have commented on this site have similar stories to tell. I'm sure that drug companies impact prescribing decisions, but I have no personal experience of that affecting my treatment. I have been on this same SSRI for more than 10 years now and it effectively prevents panic attacks.
Sorry, you’re right, my first comment lacks nuance and was too one-sided.
Yes, SSRIs have a quite powerful anxiolytic effect. It was Donald Klein who along with Max Fink discovered in 1962 and further reported on in 1964 that the first antidepressant imipramine could effectively terminate panic attacks.
https://link.springer.com/article/10.1007/BF02193476
His description of the specific type of attack is as follows:
"Typically, these patients noted the sudden onset of subjectively
inexplicable panic attacks, accompanied by hot and cold flashes, rapid
breathing, palpitations, weakness, unsteadiness and a feeling of impending
death."
While SSRIs can work well as anxiolytics, there has long been debate about whether they have as marked an effect on true panic attacks. So, perhaps you can help answer a burning scientific question: the panic attacks you experienced, were they “bolt-from-the-blue” episodes with sudden hyperventilation to the point of near blacking out followed by fear, or were they more like an overwhelming surge of anxiety that came from nowhere and involved only slight hyperventilation?
Just to clarify a litte more what I was getting at before:
The point I was trying to make is that the “your mileage may vary” mantra is a thought-terminating cliché. It’s like, when Tony Soprano says “yeah, but what are you going to do about it?”. It’s a throwaway line that immediately stops people thinking any harder about the problem.
It also teaches consumers that their experiences are part of some cosmic mystery, to be accepted, not investigated. A bit like the saying some religious folk once had, “the Lord works in mysterious ways”, so too, according to some, do all psychiatric drugs. There might be a kernel of wisdom in accepting that these drugs can be a little mysterious, but it is hardly satisfactory to leave the matter at that.
I believe that when you listen to people's lived experiences, you start to see patterns. You start to realise that many people have had the same experience. You start to realise that some of these experiences may be explainable. You start to realise that people deserve answers.
Once again, an approach to psychiatry that is hyperindividualistic, and rooted in the computer model. But humans are not fundamentally individualistic, we begin life as a dyad (mother-infant) and the quality of that dyad is literally of life and death importance. We continue through life as nodes in a web of relationships, with our moods, behaviors, and thoughts profoundly shaped by this web. WE value connection and relational warmth in the web more than we value alleviation of our suffering. Clients are willing "to receive an intervention that had a lower recovery rate by 38.14% to ensure that they received a therapist with whom they
could develop a positive working relationship. " JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(12), 1217--1231 (2010). Until theories of mental health/disorder start from perspective of the relationships between people, they will be woefully incomplete, giving into the reductionism of science, rather than the social web that weaves us together from infancy to death.
Relational aspects are of course quite important and not denied by neuroscience. It is difficult to study the brain without taking into account social and environmental interactions, especially during development, and systems neuroscience is interested in that. Neuroscience is not a substitute for psychological and social disciplines; some things are better studied by other disciplines and that’s not changing. You may not believe that neuroscience is of any importance to the study of mental health problems and to the development of new treatments. I don’t agree with that but I know some people hold that view. For those of us who do believe in the importance and relevance of neuroscience (along with other disciplines), these developments are positive and promising. Neuroscience is still in infancy and there is a long way to go.
Ruth Feldman's brilliant work shows that the infant's brain is wired by the interactions with the mother, and its socio-emotional development is highly dependent on this wiring. This carries on for years, as "Exposure to childhood sexual abuse was specifically associated with pronounced
cortical thinning in the genital representation
field of the primary somatosensory cortex. In
contrast, emotional abuse was associated with
cortical thinning in regions relevant to self-awareness
and self-evaluation (Am J Psychiatry 2013; 170:616–623) It is only by understanding the web of relationships the person was raised in, and interacts in, that we can make sense of the results of current neuroscience findings.
If you ask me, modern psychiatry just has a Tommy Nookah problem.
Jeez Awais, maybe the problem is you came along to late.